Can anyone tell me how to select the "R/T" with a diagnosis of "Decreased Cardiac Output"? I have identified the following defining characteristics in the nursing diagnosis manual that I guess would be the "AEB"?-- tachycardia (108 BPM); observable shortness of breath and variations in bp readings (162/88). I want to put "congestive heart failure" as the r/t but it's a medical diagnosis so I can't use it right?
The patient situation is as follows: 68 year old male who was admitted to your medical-surgical unit with a diagnosis of congestive heart failure. He reports Heart Rate (HR) 108 BPM, Blood Pressure (BP) 162/88, Temperature (T) 100.2 degrees orally, his respiratory rate (RR) is 24.
The patient is short of breath, has difficulty talking in full sentences, and can only walk short distances without becoming dizzy and winded. He appears to be very unsteady on his feet.
Thanks for your help!
Jan 21, '12
by Esme12, ASN, BSN, RN
first of all what is chf?
heart failure, also known as congestive heart failure (chf), means the heart can't pump enough blood to meet the body's needs. over time, conditions such as narrowed arteries in the heart (coronary artery disease) or high blood pressure gradually leave the heart too weak or stiff to fill and pump efficiently.
heart failure (hf) often called congestive heart failure (chf) is generally defined as the inability of the heart to supply sufficient blood flow to meet the needs of the body. heart failure is a global term for the physiological state in which
cardiac output is insufficient in meeting the needs of the body and lungs. often termed "congestive heart failure" or chf, this is most commonly caused when cardiac output is low and the body becomes congested with fluid
here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan
- assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care
plans and the nursing process. . .a care plan
is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is
a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories http://allnurses.com/general-nursing...ns-286986.html
always think abc's and with the complait of being dizzy i would think safety wuld be a concern as well. you may find these helpful...
Last edit by Esme12 on Jan 21, '12
of course. your nursing dx can have multlple causes, so you can list multiple causes. and you can list a medical dx as a cause, because, well, it can be the cause of the symptoms you cite as evidence for your nursing diagnosis.
have you actually looked in the nanda book? all of that is quite clear...and really will help you out with questions like this!
Last edit by GrnTea on Jan 29, '12